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BlueCard Out of Area PPO
Benefits at a GlanceA PPO, or Preferred Provider Organization, offers two levels of benefits. If you receive services from a provider who is in the PPO network you'll receive the highest level of benefits. If you receive services from a provider who is not in the PPO network you'll receive the lower level of benefits. In either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. Below are specific benefit levels. Wish to have a printable version of this benefit grid? A simple click will open a pdf version...BlueCard OOA The following benefits are effective January 1, 2004. Please click on the Site Map to view benefit information for the 2003 plan year.
1Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group's prescription drug program. 2If Blue Cross Blue Shield is not contacted 7-14 days prior to an inpatient admission and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, the patient will be responsible for payment of any costs not covered. 3Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. Under the mandatory generic provision, the member is responsible for the payment differential when a generic drug is available and the doctor or patient specifies a brand name drug. The member payment is the price difference between the brand drug and the generic drug in addition to the brand drug Co-Pay or coinsurance amounts which may apply. The benefit summary outlines the principal features of the program. It should
not be considered the contract of benefits and provisions. Please refer to your
member handbook for a complete description of benefits or Provider NetworkMembers can use the RatesTo determine premium rates, Highmark Blue Cross Blue Shield uses a demographic rating method based on the following factors: business location, the number of eligible employees enrolling, the average age of all covered employees, and industry classification. Please contact the Council's Employee Benefits Group to determine your specific rates. Highmark DisclaimerHighmark Blue Cross Blue Shield® is an independent licensee of the Blue Cross and Blue Shield Association serving businesses and residents in western Pennsylvania. Highmark® is a registered service mark of Highmark Inc. Blue Cross and Blue Shield® and the cross and shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Blues on CallSM is a service mark of the Blue Cross and Blue Shield Association. This information is not intended for use without professional advice. While we have attempted to make this site as accurate as possible, it is only a summary. For more information, see our disclaimer.
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